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Skin cancer risk factors

Risk factors for malignant melanoma of the skin and non-melanoma skin cancer (NMSC) are discussed on this page. These include ultraviolet radiation (from sun exposure and sunbeds), skin type and hair and eye colour, sunscreen use, family history, previous cancer, and other medical conditions. 

Malignant melanomas can also occur in other body organs, such as the eye, but such melanomas are not discussed here. On this page “malignant melanoma” refers to malignant melanoma of the skin only.

In the sections which follow, meta-analyses and systematic reviews are cited where available, as they provide the best overview of all available research and often take study quality into account. Individual case-control and cohort studies are reported where good quality aggregated data are lacking.

 

Ultraviolet radiation from sun exposure

Excess exposure to ultraviolet (UV) radiation is the main preventable risk factor for skin cancer.1,2 The sun is the principal source of natural UV radiation (Figure 4.1). Sunbeds produce artificial UV radiation.

Figure 4.1: Solar UV Radiation in Relation to the Earth and Ozone Layer

cs_mel_f4

UVA and UVB are the two types of solar radiation which reach us on Earth. Both types are linked to skin cancer. UVB is predominantly responsible for burning, whilst UVA penetrates deeper into the skin and is linked with premature ageing.

It is also expected that climate change will cause more skin cancer cases in the future, as more UV radiation reaches us on Earth, and warmer temperatures encourage people to spend more time in direct sunlight.98

There is sufficient evidence that too much exposure to solar UV radiation is the main cause of both malignant melanoma and NMSC in humans, according to the International Agency for Research on Cancer (IARC).3,4 It is estimated that around 11,100 (86%) malignant melanoma cases in the UK in 2010 were linked to UV radiation exposure.1 Among NMSCs, an estimated 50-70% of squamous cell carcinomas (SCCs) and 50-90% of basal cell carcinomas (BCCs) in fair-skinned people are caused by UV radiation.5

Intermittent sun exposure and sunburn

Risk of malignant melanoma is most strongly linked to intermittent exposure to high-intensity sunlight (for example from sunbathing, doing watersports or holidaying in a place where the sun is strong), a meta-analysis has shown.6 Intermittent sun exposure was associated with a 60% increased risk of malignant melanoma, though this effect was smaller and not significant in studies of UK, US, Canadian or Australian populations.6

Intermittent exposure to high-intensity sunlight often results in sunburn,6 and a history of sunburn doubles the risk of malignant melanoma.6,7 Having had 26 or more episodes of ‘painful’ or ‘severe’ sunburn during your lifetime increases the risk of malignant melanoma by two to three times in women, a pooled analysis showed.8 Malignant melanoma risk is increased regardless of whether sunburn occurred in childhood or adulthood.6,9

Sunburn, especially in childhood, or intermittent exposure to sunlight, also increases the risk of BCC.10,15 Sunburn and intermittent sunlight exposure is associated to a lesser extent with SCC risk.12,14,16,130

Exposure to UV radiation has increased in recent decades in the UK population, as people have increasingly sought a suntan by holidaying abroad.

Chronic sun exposure

Chronic or more continuous sunlight exposure, for example that received by people with outdoor occupations, did not appear to increase malignant melanoma risk in a recent meta-analysis, though the review authors commented that occupational sun exposure still probably increases risk over no sun exposure at all.6

There is evidence that chronic sun exposure increases the risk of NMSC. People who work outdoors are at 43% higher risk of BCC,17 and 77% higher risk of SCC,18 and these effects are stronger in countries nearer the equator, two meta-analyses have found.17,18

section reviewed 19/07/13
section updated 19/07/13

 

Ultraviolet radiation from sunbeds

There is sufficient evidence that use of sunbeds causes malignant melanoma, IARC states.4 IARC also states there is limited evidence that sunbed use causes SCC.4 There is currently no IARC statement on sunbeds and BCC.

Use of a sunbed for the first time before age 35 increases the risk of malignant melanoma by 59%, and use at any age increases malignant melanoma risk by 20-25%, the most recent meta-analysis showed.19,103 Women using a sunbed once a month or more in their 30s increase their malignant melanoma risk by 49%, and those doing so in their 40s face a 61% increased risk, one large study included in that analysis showed.20 Another cohort study showed women aged 25-39 who use a sunbed more than 10 times a year have two-and-a-half times the malignant melanoma risk compared with women who do not use sunbeds.123 Sunbed use is estimated to cause around one hundred deaths a year from malignant melanoma in the UK.19,21

Sunbed use at any age increases the risk of SCC by 67%, and increases BCC risk by 29%, according to the most recent meta-analysis.101 Risk increases for both types of NMSC in relation to sunbed use were also shown in an earlier meta-analysis.19 Exposure before age 25 appears to confer even greater risk increases, though in meta-analysis the effect was significant only for BCC (40% risk increase).101   Women who used a sunbed more than six times a year during high school increased their BCC risk by 73% in comparison with those who didn’t use a sunbed, a US cohort study showed.120 And both SCC and BCC risk were increased by 15% for every four sunbed sessions a year during high school or at age 25-35.120

Using a sunbed without ever burning appears to be no safer – it can increase the risk of malignant melanoma and early-onset BCC (diagnosed in people under 40 years old) by more than 60%, recent case-control studies have shown.22,23 SCC risk is around doubled in women who ever used a sunbed before age 50, compared with never-users, a Nordic cohort study showed.130

Prevalence of sunbed use

In 1999 a quarter of men and a third of women in Britain reported trying to get a tan in the previous six months. There were even higher rates amongst younger people (Figure 4.2). Overall, 2% of adults trying to get a tan did so using a sunbed or tanning machine only.24  In 2008 and 2009, 6% of 11-17-year-olds in England reported they had used a sunbed,25 and in 2008, 5% of under-25s in Northern Ireland reported currently using sunbeds.26

Use of sunbeds by under-18s is now banned across the UK, with legislation passed in Scotland in 2009, England and Wales in 2011, and Northern Ireland in May 2012.

Figure 4.2: Proportion of Adults that Tried to get a Tan in the Last Six Months, Great Britain, 1999

cs_mel_f4.2.swf

Download this chart XLS (55KB)

The possibility that younger people and those with high-risk skin types are at greatest risk of skin cancer due to sunbed use is widely recognised. In 2003 the International Commission on Non-Ionizing Radiation Protection (ICNIRP) and the World Health Organisation (WHO) recommended that certain categories of people should not use sunbeds (Table 4.1).27,28 ICNIRP also concluded that anyone using suntanning appliances is likely to raise their risk of skin cancer, eye damage, photodermatosis, photosensitivity and premature skin ageing.27 Cancer Research UK recommends that people do not use sunbeds.

Table 4.1: Categories of People who Should Not Use Sunbeds, as Recommended by ICNIRP and WHO

People who have skin phototypes I or II (see Table 4.2 for definition)
Children (i.e. less than 18 years of age)
People who have large numbers of naevi (moles)
People who tend to freckle
People who have a history of frequent childhood sunburn
People who have pre-malignant or malignant skin lesions
People who have sun-damaged skin
People who are wearing cosmetics - these may enhance their sensitivity to UV exposure
People taking medications which make them UV-sensitive.

section reviewed 19/07/13
section updated 19/07/13

 

Skin type, hair and eye colour

People with light eyes, skin or hair, or with skin that sunburns easily or does not tan, have an increased risk of skin cancer.10,11,14,29,30 These factors in combination are used to define the skin phototype (Table 4.2). This classification is used in most studies exploring pigmentary characteristics and skin cancer risk.29

Table 4.2: Skin Phototypes

Skin Phototype Typical Features Tanning Ability
Type I Tends to have freckles, red or fair hair, and blue or green eyes. Often burns, rarely tans.
Type II Tends to have light hair, and blue or brown eyes. Usually burns, sometimes tans.
Type III Tends to have brown hair and eyes. Sometimes burns, usually tans.
Type IV Tends to have dark brown eyes and hair. Rarely burns, often tans.
Type V Naturally black-brown skin. Often has dark brown eyes and hair.  
Type VI Naturally black-brown skin. Usually has black-brown eyes and hair.  

Based on: Fitzpatrick T. Soleil et peau. J Med Esthet 1975;2:33-4.

In comparison with people with skin phototype IV, those with skin phototype I are at more than double (2.27 times) the malignant melanoma risk, phototype II at double (1.99 times) the risk, and phototype III at 35% increased risk, a recent meta-analysis reported.29

Table 4.3 gives incidence rates for malignant melanoma by major ethnic group in England.31

Table 4.3: Ranges of Age-Standardised Incidence Rates per 100,000 Population for Malignant Melanoma, 2002-2006 by Major Ethnic Group and Sex, England

  Males Females
White 13.1-13.6 14.7-15.2
Asian 0.2-0.8 0.2-1.1
Black 0.6-2.6 1.0-3.6

In comparison with dark-eyed people, those with blue/blue-grey eyes have a 57% higher malignant melanoma risk, and those with green/grey/hazel eyes have a 51% increased risk.29

In comparison with dark-haired people, those with red/red-blonde hair were shown to be at up to triple the malignant melanoma risk.29,32 Blondes are at double the risk, and people with light brown hair are at 46% increased risk.29

People with freckles were found to have around double (1.99 times) the risk of malignant melanoma, versus people without freckles.29 People with freckles have increased malignant melanoma risk, regardless of the number of moles they have.33

People with blue/green-blue/green-grey eyes are at increased risk of BCC.34 People with red and light-coloured hair are at increased risk of BCC and SCC.35-37

section reviewed 19/07/13
section updated 19/07/13

 

Moles (naevi)

Meta-analyses show people with any unusually shaped or large moles (also called atypical naevi; these are usually larger than common naevi, with a more variegated appearance; poorly-defined border, and some areas slightly raised) have around four to ten times increased risk of malignant melanoma,38,39 and the risk increases with the number of atypical moles.38 People with very high numbers (100+) of common moles on their bodies have nearly seven times the risk compared to people with very few (0-15 moles),38 and every additional common mole increases the risk of malignant melanoma by around 2%.39

People with dysplastic mole syndrome (also known as Familial Atypical Multiple Mole-Melanoma Syndrome or FAMMM; characterised by multiple atypical moles that continue to appear in adulthood) and a family history of malignant melanoma have a 500-fold increased risk of developing malignant melanoma;40 however this is very rare and accounts for less than 5% of malignant melanoma cases.38

Most moles are genetically determined (inherited), though sun exposure can increase the number of moles. Most moles appear during childhood.33,41 The emergence of moles in adolescents is under strong genetic control, a UK study of moles in twins concluded.42 Chronic sun exposure rather than number of sunburn episodes is the most important environmental factor determining mole development.33

section reviewed 19/07/13
section updated 23/07/12

 

Sunscreen use

The impact of sunscreen use on skin cancer risk remains unclear, due largely to methodological limitations.43,44

Sunscreen should be used together with clothing and shade to protect the skin from sun damage, and should never be used to spend longer in the sun. Research shows sunscreen users may counteract the protective effect of sunscreens by: spending longer in the sun than non-users; applying their sunscreen incorrectly; or failing to use protective clothing.45-48

section reviewed 19/07/13
section updated 23/07/12

 

Vitamin D

The only established benefit of exposure to solar UV radiation is the synthesis of vitamin D, which is vital for bone health. Higher circulating levels of vitamin D in the blood are associated with lower risk of bowel cancer, although it is unclear whether this is a causal relationship.49-53

However, sunbathing, tanning or burning should not be necessary to make sufficient vitamin D to obtain health benefits. In fair-skinned people, the time taken to make enough vitamin D is short, and less than the time taken for skin to redden or burn.54 Once sufficient vitamin D is made, any extra is turned into inactive substances.55 So more sun exposure does not equate to greater health benefits, and excessive exposure to solar UV radiation is not a means of reducing the incidence or mortality of cancer.

section reviewed 19/07/13
section updated 23/07/12

 

Family history and genetic conditions

Family history

Malignant melanoma risk is around doubled in people with a family history of the same disease, versus people without such a family history, meta-analyses and a cohort study have shown.56,57,132 Risk is highest if the affected relative is aged under 30, or more than one first-degree relative is affected, a cohort study showed.132 Inherited risk accounts for around 10% of malignant melanoma cases.58,59

SCC risk is increased in people with a family history of the same disease, a cohort study has shown.63

BCC risk is increased in people with a family history of malignant melanoma, a cohort study has shown.64

Genetic conditions

Malignant melanoma risk is higher in Europeans with CDKN2A mutation, characteristic of familial atypical multiple mole melanoma (FAMM); around 6 in 10 develop malignant melanoma by age 80.60,61

Malignant melanoma and NMSC risk may be increased in Li Fraumeni syndrome.62

section reviewed 22/04/14
section updated 22/04/14

 

Previous cancer

Previous malignant melanoma is associated with 8-15 fold increased risk of a second malignant melanoma, multiple cohort studies have shown.65,66,116,131 The effect is stronger for women.65,66 People with a previous malignant melanoma and a parent with malignant melanoma are at more than 30-fold risk of a second malignant melanoma.67 Malignant melanoma risk is higher among people with a previous diagnosis of various other cancers, including female breast cancer;68,69 non-Hodgkin lymphoma;70,71 renal cell carcinoma;72 certain childhood cancers;73,115 prostate cancer;68,74,125 thyroid cancer;68 and leukaemia.68 Generally the increase in risk was less than double. Often these associations are bi-directional,66 supporting shared genetic or environmental factors.

Previous SCC is associated with ten times higher risk of a second BCC or SCC, whilst previous BCC is associated with ten times higher risk of second BCC but a lower increase in second SCC risk.75-77 Previous malignant melanoma is associated with three-fold increased risk of NMSC.78 People who have had NMSC are also at increased risk of other second primary cancers.79

section reviewed 14/04/14
section updated 14/04/14

 

Other medical conditions, treatments and procedures

Organ transplant recipients are at 29-fold increased NMSC risk, and two-fold increased malignant melanoma risk, a meta-analysis shows.80-82 This may be related to the use of immunosuppressant drugs called azathioprine and cyclosporine, which IARC states are causes of NMSC.4

People with Crohn's disease have an 80% increased risk of malignant melanoma, and people with ulcerative colitis have a 23% increased risk, a meta-analysis shows.107 Treatment for these bowel conditions may include immunosuppressant drugs, but the increase in malignant melanoma risk appears to be independent of treatment.107

People with atopic dermatitis (the most common form of eczema) appear to have an increased risk of NMSC, but the association between atopic dermatitis and malignant melanoma remains unclear.83,84 Contact allergy may reduce the risk of NMSC very slightly.85 A drug called methoxsalen is used in conjunction with exposure to UVA to treat eczema, and IARC classifies this as a cause of NMSC.4 Patients with severe psoriasis may have seven times the NMSC risk of the general population, and eleven times the malignant melanoma risk, a cohort study showed.113

Malignant melanoma risk is apparently doubled in men with Parkinson’s disease, but there is no significant association for women, a meta-analysis showed.86 Subsequent cohort studies have found a smaller effect (41%-53% increase in men and women combined) with similar magnitude in both sexes.121,124 NMSC risk was 29% higher in Parkinson’s disease patients in that cohort study, but the meta-analysis found no significant association.86,121

Rheumatoid arthritis patients taking tumour necrosis factor inhibitors (anti-TNF-α) may have increased NMSC risk, but the evidence remains unclear: a meta-analysis of randomised controlled trials found the effect was not significant,109 but a meta-analysis of observational studies found a 45% higher risk of NMSC.87 Rheumatoid arthritis patients taking anti-TNF-α do not have a higher NMSC risk than patients taking other disease-modifying anti-rheumatic drugs,99 nor does their malignant melanoma risk appear to be significantly altered.87

People with HIV or AIDS have been shown to have increased malignant melanoma and NMSC risks;80 presently IARC states that there is limited evidence that HIV type 1 infection causes NMSC.4

section reviewed 19/07/13
section updated 19/07/13

 

Other risk factors

For every 5cm increase in height, malignant melanoma risk is 17% higher in females and 13% higher in males, and NMSC risk is 12% higher in females and 10% higher in males, a pooled analysis of Nordic data showed.127 One study showed women taller than 5 feet 3 inches were at 28-64% higher BCC risk than shorter women.34  Malignant melanoma risk in women increased by 32%-51% for every 10cm increase in height, according to recent large studies.88,100

Malignant melanoma risk is 31% higher in overweight (body mass index (BMI) 25-29.9) and obese (BMI 30+) men, compared with men whose BMI is lower than 25, a meta-analysis reported.108 This analysis showed the risk appears to plateau in overweight men rather than continuing to increase with higher BMI,108 however a previous meta-analysis found  a 17% risk increase per 5-unit BMI increment. 89 Case-control studies show that women with higher BMI or body surface area have an increased malignant melanoma risk, when results are adjusted for the amount of sun exposure, suggesting mutual confounding between body size and sun exposure (e.g. larger women self-limit their public sun exposure).108 However, most studies have not adjusted for amount of sun exposure and have not found an association between overweight and malignant melanoma risk in women.89,90,108 Obesity is associated with decreased NMSC risk, perhaps due to less UV exposure in larger people.91,118 Women with BMI lower than 25kg/m2 were at 26-43% higher BCC risk and 20-41% higher SCC risk than women with a higher BMI, US cohort studies have shown.34,91 For men in these analyses, the difference in BCC risk was only significant for people with BMI 30-34.99 versus BMI under 25, and there was no significant effect of BMI on SCC risk.34,91 Babies with a higher birthweight have a higher risk of early-onset malignant melanoma, a Northern Ireland cohort study showed; those weighing 4.5-6kg at birth had more than twice the malignant melanoma risk compared with those weighing 3-3.5kg at birth.114

There is sufficient evidence that X-radiation and gamma radiation (both types of ionising radiation) cause NMSC, according to IARC.4 Radiotherapy for a previous cancer is estimated to have caused 17.9% of second primary malignant melanoma cases in women and 2.8% of second primary malignant melanoma cases in men in 2010.92 Exposure to cosmic radiation has been posited as an explanation for the higher rates of malignant melanoma in airline staff, but recent evidence suggests that excessive UV exposure and sun-sensitive skin phenotypes are more likely causes.93,94 People who receive at least one computed tomography (CT) scan of the brain before age 20 have a 14% higher risk of malignant melanoma or NMSC, with no significant effect of CT scans to other anatomical sites, a large Australian cohort study showed.112

Some chemical exposures that can take place in certain occupations cause NMSC, IARC states.4 These include coal tar pitch, soot, mineral oils and shale oils. It has been estimated that around 7% of NMSCs in men and around 1% in women in Britain are due to occupational exposures (including solar radiation).95

People diagnosed with genital warts (associated with infection with HPV types 6 and 11) have a 30% increased risk of BCC.102

section reviewed 06/12/13
section updated 06/12/13

Factors shown to have no effect on skin cancer risk

Exogenous hormones

Use of oral contraceptives (OCs) or hormone replacement therapy (HRT) does not significantly impact on malignant melanoma risk in women, a meta-analysis shows.96 Other reproductive factors (age at birth of first child, number of children) show small effects on malignant melanoma risk, though these effects are largely explained by socio-economic factors.96 SCC risk increased by 35% for every five years of HRT use in a cohort study, and BCC risk was 15% higher in women who had ever used HRT compared to those who had never used it.122 OC use did not impact on BCC or SCC risk in this cohort study.122

section reviewed 06/12/13
section updated 06/12/13

Smoking

Unlike for many other cancers, smoking does not appear to increase malignant melanoma risk .4,110 The relationship between smoking and NMSC risk remains unclear, with effects apparently varying by NMSC type, and patient sex.97,110 Alcohol consumption may increase malignant melanoma and NMSC risk, but findings remain mixed.4,117,126

section reviewed 06/12/13
section updated 06/12/13

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) appear not to affect malignant melanoma risk, meta-analyses show.104,105 Case-control studies indicate aspirin may slightly reduce malignant melanoma risk, but no effect is seen in cohort studies – and because of the potential adverse consequences of high intake of aspirin, such as gastrointestinal haemorrhage, it would not be recommended as a prophylactic measure.104,105

section reviewed 06/12/13
section updated 06/12/13

Diet

Low-fat diet does not appear to affect malignant melanoma risk in women, a US cohort study showed.111 Folic acid supplements were shown to have no effect on malignant melanoma risk in the largest meta-analysis to date,106 Vitamin A and carotenoids intake did not affect malignant melanoma risk in a large cohort study.119 Omega-3-fatty acid intake is not associated with SCC or BCC risk, a meta-analysis showed.128

section reviewed 06/12/13
section updated 06/12/13

Statins

Melanona risk is not associated with statin use, a meta-analysis showed.129 Non-melanoma skin cancer risk is also not associated with statin use.129

section reviewed 10/04/14
section updated 10/04/14

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References for skin cancer risk factors

  1. Parkin DM, Mesher D, Sasieni P. 13. Cancers attributable to solar (ultraviolet) radiation exposure in the UK in 2010. Br J Cancer 2011;105 Suppl 2:S66-9.
  2. Leiter U, Garbe C. Epidemiology of melanoma and nonmelanoma skin cancer--the role of sunlight. Adv Exp Med Biol 2008;624:89-103.
  3. International Agency for Research on Cancer. Solar and ultraviolet radiation (Vol 55). Monographs on the evaluation of carcinogenic risks to humans. Lyon: IARCPress; 1992.
  4. Cogliano VJ, Baan R, Straif K, et al. Preventable exposures associated with human cancers. J Natl Cancer Inst 2011;103:1827-39.
  5. Lucas RM, McMichael AJ, Armstrong BK, et al. Estimating the global disease burden due to ultraviolet radiation exposure. International Journal of Epidemiology 2008;37:654-67.
  6. Gandini S, Sera F, Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. European Journal of Cancer 2005;41:45-60.
  7. Elwood JM, Jopson J. Melanoma and sun exposure: an overview of published studies. Int J Cancer 1997;73:198-203.
  8. Olsen CM, Zens MS, Green AC, et al. Biologic markers of sun exposure and melanoma risk in women: Pooled case–control analysis. Int J Cancer 2011;129:713-23.
  9. Dennis LK, Vanbeek MJ, Beane Freeman LE, et al. Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis. Ann Epidemiol 2008;18:614-27.
  10. Pelucchi C, Di Landro A, Naldi L, et al. Risk factors for histological types and anatomic sites of cutaneous basal-cell carcinoma: an italian case-control study. J Invest Dermatol 2007;127:935-44.
  11. Gallagher RP, Hill GB, Bajdik CD, et al. Sunlight exposure, pigmentary factors, and risk of nonmelanocytic skin cancer. I. Basal cell carcinoma. Arch Dermatol 1995;131:157-63.
  12. Zanetti R, Rosso S, Martinez C, et al. Comparison of risk patterns in carcinoma and melanoma of the skin in men: a multi-centre case-case-control study. Br J Cancer 2006;94:743-51.
  13. Kennedy C, Bajdik CD, Willemze R, et al. The Influence of Painful Sunburns and Lifetime Sun Exposure on the Risk of Actinic Keratoses, Seborrheic Warts, Melanocytic Nevi, Atypical Nevi, and Skin Cancer. J Invest Dermatol 2003;120:1087-93.
  14. Rosso S, Zanetti R, Martinez C, et al. The multicentre south European study 'Helios'. II: Different sun exposure patterns in the aetiology of basal cell and squamous cell carcinomas of the skin. Br J Cancer 1996;73:1447-54.
  15. Corona R, Dogliotti E, D'Errico M, et al. Risk factors for basal cell carcinoma in a Mediterranean population: role of recreational sun exposure early in life. Arch Dermatol 2001;137:1162-8.
  16. Steding-Jessen M, Birch-Johansen F, Jensen A, et al. Socioeconomic status and non-melanoma skin cancer: A nationwide cohort study of incidence and survival in Denmark. Cancer Epidemiology 2010;34:689-95.
  17. Bauer A, Diepgen TL, Schmitt J. Is occupational solar ultraviolet irradiation a relevant risk factor for basal cell carcinoma? A systematic review and meta-analysis of the epidemiological literature. Br J Dermatol 2011;165:612-25.
  18. Schmitt J, Seidler A, Diepgen TL, Bauer A. Occupational ultraviolet light exposure increases the risk for the development of cutaneous squamous cell carcinoma: a systematic review and meta-analysis. Br J Dermatol 2011;164:291-307.
  19. Boniol M, Autier P, Boyle P, et al. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ 2012;345:e4757 doi: 10.1136/bmj.e4757.
  20. Veierod MB, Adami HO, Lund E, et al. Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi. Cancer Epidemiol Biomarkers Prev 2010;19:111-20.
  21. Diffey BL. A quantitative estimate of melanoma mortality from ultraviolet A sunbed use in the U.K. Br J Dermatol 2003;149:578-81.
  22. Ferrucci LM, Cartmel B, Molinaro AM, et al. Indoor tanning and risk of early-onset basal cell carcinoma. J Am Acad Dermatol. 2011.
  23. Lazovich D, Vogel RI, Berwick M, et al. Indoor Tanning and Risk of Melanoma: A Case-Control Study in a Highly Exposed Population. Cancer Epidemiol Biomarkers Prev 2010;19:1557-68.
  24. Office for National Statistics. ONS Omnibus Survey, Knowledge of the Solar UV Index. 2000.
  25. Thomson CS, Woolnough S, Wickenden M, et al. Sunbed use in children aged 11-17 in England: face to face quota sampling surveys in the National Prevalence Study and Six Cities Study. BMJ 2010;340.
  26. Boyle R, O’Hagan AH, Donnelly D, et al. Trends in reported sun bed use, sunburn, and sun care knowledge and attitudes in a U.K. region: results of a survey of the Northern Ireland population. Br J Dermatol 2010;163:1269-75.
  27. International Commission on Non-Ionizing Radiation Protection. Health issues of ultraviolet tanning appliances used for cosmetic purposes. Health Phys 2003;84:119-27.
  28. World Health Organization. Artificial tanning sunbeds: risk and guidance. 2003.
  29. Olsen CM, Carroll HJ, Whiteman DC. Estimating the attributable fraction for melanoma: a meta-analysis of pigmentary characteristics and freckling. Int J Cancer 2010;127:2430-45.
  30. Fitzpatrick T. Soleil et peau. J Med Esthet 1975;2:33-4.
  31. National Cancer Intelligence Network and Cancer Research UK. Cancer incidence and survival by major ethnic group, England, 2002-2006. London: NCIN; 2009.
  32. Williams PF, Olsen CM, Hayward NK, et al. Melanocortin 1 receptor and risk of cutaneous melanoma: a meta-analysis and estimates of population burden. Int J Cancer 2011;129:1730-40.
  33. Bauer J, Garbe C. Acquired Melanocytic Nevi as Risk Factor for Melanoma Development. A Comprehensive Review of Epidemiological Data. Pigment Cell Res 2003;16:297-306.
  34. Gerstenblith MR, Rajaraman P, Khaykin E, et al. Basal cell carcinoma and anthropometric factors in the U.S. radiologic technologists cohort study. Int J Cancer 2012;131:E149-E55.
  35. Gerstenblith MR, Shi J, Landi MT. Genome-wide association studies of pigmentation and skin cancer: a review and meta-analysis. Pigment Cell Melanoma Res 2010;23:587-606.
  36. Kiiski V, de Vries E, Flohil SC, et al. Risk factors for single and multiple basal cell carcinomas. Arch Dermatol 2010;146:848-55.
  37. Rosso S, Zanetti R, Martinez C, et al. The multicentre south European study 'Helios'. I: Skin characteristics and sunburns in basal cell and squamous cell carcinomas of the skin. Br J Cancer 1996;73:1440-6.
  38. Gandini S, Sera F, Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: I. Common and atypical naevi. European Journal of Cancer 2005;41:28-44.
  39. Olsen CM, Carroll HJ, Whiteman DC. Estimating the attributable fraction for cancer: A meta-analysis of nevi and melanoma. Cancer Prev Res (Phila) 2010;3:233-45.
  40. Greene MH, Clark JWH, Tucker MA, et al. High risk of malignant melanoma in melanoma-prone families with dysplastic nevi. Annals of Internal Medicine 1985;102:458-65.
  41. Dulon M, Weichenthal M, Blettner M, et al. Sun exposure and number of nevi in 5- to 6-year-old European children. Journal of Clinical Epidemiology 2002;55:1075-81.
  42. Wachsmuth RC, Gaut RM, Barrett JH, et al. Heritability and gene-environment interactions for melanocytic nevus density examined in a U.K. adolescent twin study. J Invest Dermatol. 2001;117:348-52.
  43. Chesnut C, Kim J. Is there truly no benefit with sunscreen use and Basal cell carcinoma? A critical review of the literature and the application of new sunscreen labeling rules to real-world sunscreen practices. J Skin Cancer 2012;2012:480985.
  44. Diffey BL. Sunscreens as a preventative measure in melanoma: an evidence-based approach or the precautionary principle? Br J Dermatol 2009;161:25-7.
  45. Weinstock MA. Do sunscreens increase or decrease melanoma risk: an epidemiologic evaluation. J Investig Dermatol Symp Proc 1999;4:97-100.
  46. Autier P, Boniol M, Dore JF. Sunscreen use and increased duration of intentional sun exposure: still a burning issue. Int J Cancer 2007;121:1-5.
  47. Dennis LK, Beane Freeman LE, VanBeek MJ. Sunscreen use and the risk for melanoma: A quantitative review. Annals of Internal Medicine 2003;139:966-78.
  48. International Agency for Research on Cancer. IARC Handbook on Cancer Prevention Vol.5: Sunscreens. 2001.
  49. Lee JE, Li H, Chan AT, et al. Circulating levels of vitamin D and colon and rectal cancer: the Physicians' Health Study and a meta-analysis of prospective studies. Cancer Prev Res (Phila) 2011;4:735-43.
  50. Ma Y, Zhang P, Wang F, et al. Association Between Vitamin D and Risk of Colorectal Cancer: A Systematic Review of Prospective Studies. Journal of Clinical Oncology 2011;29:3775-82.
  51. Mohr SB, Gorham ED, Alcaraz JE, et al. Serum 25-hydroxyvitamin D and prevention of breast cancer: pooled analysis. Anticancer Res 2011;31:2939-48.
  52. Gandini S, Boniol M, Haukka J, et al. Meta-analysis of observational studies of serum 25-hydroxyvitamin D levels and colorectal, breast and prostate cancer and colorectal adenoma. Int J Cancer 2011;128:1414-24.
  53. Chung M, Lee J, Terasawa T, et al. Vitamin D With or Without Calcium Supplementation for Prevention of Cancer and Fractures: An Updated Meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med 2011;155:827-38.
  54. International Agency for Research on Cancer. IARC Working Group Reports Volume 5: Vitamin D and Cancer. Geneva: International Agency for Research on Cancer. 2008.
  55. Webb AR, DeCosta BR, Holick MF. Sunlight regulates the cutaneous production of vitamin D3 by causing its photodegradation. J Clin Endocrinol Metab 1989;68:882-7.
  56. Olsen CM, Carroll HJ, Whiteman DC. Familial melanoma: a meta-analysis and estimates of attributable fraction. Cancer Epidemiol Biomarkers Prev 2010;19:65-73.
  57. Gandini S, Sera F, Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: III. Family history, actinic damage and phenotypic factors. Eur J Cancer 2005;41:2040-59.
  58. Law MH, Macgregor S, Hayward NK. Melanoma genetics: recent findings take us beyond well-traveled pathways. J Invest Dermatol 2012;132:1763-74.
  59. Hansen CB, Wadge LM, Lowstuter K, et al. Clinical germline genetic testing for melanoma. Lancet Oncol 2004;5:314-9.
  60. Bonadies DC, Bale AE. Hereditary melanoma. Current Problems in Cancer 2011;35:162-72.
  61. Bishop DT, Demenais F, Goldstein AM, et al. Geographical variation in the penetrance of CDKN2A mutations for melanoma. J Natl Cancer Inst 2002;94:894-903.
  62. Schneider K GJ. Li-Fraumeni Syndrome. In: Pagon RA BT, Dolan CR, et al., editors, ed. GeneReviews™ [Internet]. Seattle (WA): University of Washington; 1999 Jan 19 [Updated 2010 Feb 9].
  63. Hemminki K, Zhang H, Czene K. Time trends and familial risks in squamous cell carcinoma of the skin. Arch Dermatol 2003;139:885-9.
  64. Qureshi AA, Zhang M, Han J. Heterogeneity in host risk factors for incident melanoma and non-melanoma skin cancer in a cohort of US women. J Epidemiol 2011;21:197-203.
  65. Balamurugan A, Rees JR, Kosary C, et al. Subsequent primary cancers among men and women with in situ and invasive melanoma of the skin. J Am Acad Dermatol 2011;65:S69-77.
  66. Bradford PT, Freedman DM, Goldstein AM, et al. Increased risk of second primary cancers after a diagnosis of melanoma. Arch Dermatol 2010;146:265-72.
  67. Zhang H, Bermejo JL, Sundquist J, et al. Modification of second cancer risk after malignant melanoma by parental history of cancer. Br J Cancer 2008;99:536-8.
  68. Yang GB, Barnholtz-Sloan JS, Chen Y, et al. Risk and Survival of Cutaneous Melanoma Diagnosed Subsequent to a Previous Cancer. Archives of Dermatology 2011;147:1395-402.
  69. Goggins W, Gao W, Tsao H. Association between female breast cancer and cutaneous melanoma. Int J Cancer 2004;111:792-4.
  70. Pirani M, Marcheselli R, Marcheselli L, et al. Risk for second malignancies in non-Hodgkin’s lymphoma survivors: a meta-analysis. Annals of Oncology 2011;22:1845-58.
  71. Morton LM, Curtis RE, Linet MS, et al. Second Malignancy Risks After Non-Hodgkin's Lymphoma and Chronic Lymphocytic Leukemia: Differences by Lymphoma Subtype. Journal of Clinical Oncology 2010;28:4935-44.
  72. Liu H, Hemminki K, Sundquist J. Renal Cell Carcinoma as First and Second Primary Cancer: Etiological Clues From the Swedish Family-Cancer Database. The Journal of Urology 2011;185:2045-9.
  73. Braam KI, Overbeek A, Kaspers GJL, et al. Malignant melanoma as second malignant neoplasm in long-term childhood cancer survivors: A systematic review. Pediatric Blood Cancer 2012;58:665-74.
  74. Braisch U, Meyer M, Radespiel-Troger M. Risk of subsequent primary cancer among prostate cancer patients in Bavaria, Germany. Eur J Cancer Prev 2012.
  75. Marcil I, Stern RS. Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer. A critical review of the literature and meta-analysis. Archives of Dermatology 2000;136:1524-30.
  76. Levi F, Randimbison L, Maspoli M, et al. High incidence of second basal cell skin cancers. Int J Cancer 2006;119:1505-7.
  77. Hemminki K, Jiang Y, Steineck G. Skin cancer and non-Hodgkin's lymphoma as second malignancies. markers of impaired immune function? Eur J Cancer 2003;39:223-9.
  78. Crocetti E, Guzzinati S, Paci E, et al. The risk of developing a second, different, cancer among 14 560 survivors of malignant cutaneous melanoma: a study by AIRTUM (the Italian Network of Cancer Registries). Melanoma Res 2008;18:230-4.
  79. Wheless L, Black J, Alberg AJ. Nonmelanoma skin cancer and the risk of second primary cancers: a systematic review. Cancer Epidemiol Biomarkers Prev 2010;19:1686-95.
  80. Grulich AE, van Leeuwen MT, Falster MO, et al. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet;370:59-67.
  81. Moloney FJ, Comber H, O'Lorcain P, et al. A population-based study of skin cancer incidence and prevalence in renal transplant recipients. Br J Dermatol 2006;154:498-504.
  82. Zwald FO, Christenson LJ, Billingsley EM, et al. Melanoma in solid organ transplant recipients. American Journal of Transplantation 2010;10:1297-304.
  83. Arana A, Wentworth CE, Fernández-Vidaurre C, et al. Incidence of cancer in the general population and in patients with or without atopic dermatitis in the U.K. Br J Dermatol 2010;163:1036-43.
  84. Jensen AO, Svaerke C, Kormendine Farkas D, et al. Atopic dermatitis and risk of skin cancer: a Danish nationwide cohort study (1977-2006). Am J Clin Dermatol 2012;13:29-36.
  85. Engkilde K, Thyssen JP, Menne T, et al. Association between cancer and contact allergy: a linkage study. BMJ Open 2011;1:e000084.
  86. Liu R, Gao X, Lu Y, et al. Meta-analysis of the relationship between Parkinson disease and melanoma. Neurology 2011;76:2002-9.
  87. Mariette X, Matucci-Cerinic M, Pavelka K, et al. Malignancies associated with tumour necrosis factor inhibitors in registries and prospective observational studies: a systematic review and meta-analysis. Ann Rheum Dis 2011;70:1895-904.
  88. Green J, Cairns BJ, Casabonne D, et al. Height and cancer incidence in the Million Women Study: prospective cohort, and meta-analysis of prospective studies of height and total cancer risk. Lancet Oncol 2011;12:785-94.
  89. Renehan AG, Tyson M, Egger M, et al. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008;371:569-78.
  90. Olsen CM, Green AC, Zens MS, et al. Anthropometric factors and risk of melanoma in women: A pooled analysis. Int J Cancer 2008;122:1100-8.
  91. Pothiawala S, Qureshi A, Li Y, et al. Obesity and the incidence of skin cancer in US Caucasians. Cancer Causes and Control 2012;23:717-26.
  92. Parkin DM, Darby SC. 12. Cancers in 2010 attributable to ionising radiation exposure in the UK. Br J Cancer 2011;105 Suppl 2:S57-65.
  93. Dos Santos Silva I, De Stavola B, Pizzi C, et al. Cancer incidence in professional flight crew and air traffic control officers: Disentangling the effect of occupational versus lifestyle exposures. Int J Cancer 2012.
  94. Tokumaru O, Haruki K, Bacal K, et al. Incidence of cancer among female flight attendants: a meta-analysis. J Travel Med 2006;13(3):127-32.
  95. Young C, Rushton L. Occupational cancer in Britain: Skin cancer. Br J Cancer 2012;107 Suppl 1:S71-5.
  96. Gandini S, Iodice S, Koomen E, et al. Hormonal and reproductive factors in relation to melanoma in women: Current review and meta-analysis. European Journal of Cancer 2011;47:2607-17.
  97. Leonardi-Bee J, Ellison T, Bath-Hextall F. Smoking and the Risk of Nonmelanoma Skin Cancer: Systematic Review and Meta-analysis. Arch Dermatol 2012:1-8.
  98. Diffey B. Climate change, ozone depletion and the impact on ultraviolet exposure of human skin. Phys Med Biol 2004 Jan 7;49(1):R1-11.
  99. Le Blay P, Mouterde G, Barnetche T, et al. Risk of malignancy including non-melanoma skin cancers with anti-tumor necrosis factor therapy in patients with rheumatoid arthritis: meta-analysis of registries and systematic review of long-term extension studies. Clin Exp Rheumatol 2012;30(5):756-642.
  100. Kabat GC, Heo M, Kamensky V, et al. Adult height in relation to risk of cancer in a cohort of Canadian women. Int J Cancer 2012. doi: 10.1002/ijc.27704.
  101. Wehner MR, Shive ML, Chren MM, et al. Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis. BMJ 2012;345:e5909. doi: 10.1136/bmj.e5909.
  102. Blomberg M, Friis S, Munk C, et al. Genital warts and risk of cancer: a Danish study of nearly 50 000 patients with genital warts. J Infect Dis 2012;205(10):1544-53.
  103. Boniol M, Autier P, Boyle P, et al. Correction to Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ 2012;345:e8503.
  104. Li S, Liu Y, Zeng Z, et al. Association between non-steroidal anti-inflammatory drug use and melanoma risk: a meta-analysis of 13 studies. Cancer Causes Control May 2013 doi: 10.1007/s10552-013-0227-8.
  105. Hu H, Xie Y, Yang G, et al. Nonsteroidal anti-inflammatory drug use and the risk of melanoma: a meta-analysis. Eur J Cancer Prev 2013 doi: 10.1097/CEJ.0b013e328360f479
  106. Vollset SE, Clarke R, Lewington S, et al. Effects of folic acid supplementation on overall and site-specific cancer incidence during the randomised trials: meta-analyses of data on 50,000 individuals. Lancet 2013;381(9871):1029-36.
  107. Singh S, Nagpal SJ, Murad MH, et al. Inflammatory Bowel Disease Is Associated With an Increased Risk of Melanoma: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2013 doi: 10.1016/j.cgh.2013.04.033.
  108. Sergentanis TN, Antoniadis AG, Gogas HJ, et al. Obesity and risk of malignant melanoma: a meta-analysis of cohort and case-control studies. Eur J Cancer 2013;49(3):642-57.
  109. Moulis G, Sommet A, Béné J, et al. Cancer risk of anti-TNF-α at recommended doses in adult rheumatoid arthritis: a meta-analysis with intention to treat and per protocol analyses. PLoS One 2012;7(11):e48991.
  110. Song F, Qureshi AA, Gao X, et al. Smoking and risk of skin cancer: a prospective analysis and a meta-analysis. Int J Epidemiol 2012;41(6):1694-705.
  111. Gamba CS, Stefanick M, Shikany J, et al. Low fat diet and skin cancer risk: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. Cancer Epidemiol Biomarkers Prev 2013. doi: 10.1158/1055-9965.EPI-13-0341
  112. Mathews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013;346 doi: 10.1136/bmj.f2360.
  113. Lee MS, Lin RY, Chang YT, et al. The risk of developing non-melanoma skin cancer, lymphoma and melanoma in patients with psoriasis in Taiwan: a 10-year, population-based cohort study. Int J Dermatol 2012;51(12):1454-60.
  114. O'Rorke MA, Black C, Murray LJ, et al. Do perinatal and early life exposures influence the risk of malignant melanoma? A Northern Ireland birth cohort analysis. Eur J Cancer 2013;49(5):1109-16.
  115. Pappo AS, Armstrong GT, Liu W, et al. Melanoma as a subsequent neoplasm in adult survivors of childhood cancer: a report from the childhood cancer survivor study. Pediatr Blood Cancer 2013;60(3):461-6.
  116. van der Leest RJ, Liu L, Coebergh JW, et al. Risk of second primary in situ and invasive melanoma in a Dutch population-based cohort: 1989-2008. Br J Dermatol 2012;167(6):1321-30.
  117. Jensen A, Birch-Johansen F, Olesen AB, et al. Intake of alcohol may modify the risk for non-melanoma skin cancer: results of a large Danish prospective cohort study. J Invest Dermatol 2012;132(12):2718-26.
  118. Pothiawala S, Qureshi AA, Li Y, et al. Obesity and the incidence of skin cancer in US Caucasians. Cancer Causes Control 2012;23(5):717-26.
  119. Asgari MM, Brasky TM, White E. Association of vitamin A and carotenoid intake with melanoma risk in a large prospective cohort. J Invest Dermatol 2012:132(6);1573-82.
  120. Zhang M, Qureshi AA, Geller AC, et al. Use of tanning beds and incidence of skin cancer. J Clin Oncol 2012;30(14):1588-93.
  121. Rugbjerg K, Friis S, Lassen CF, et al. Malignant melanoma, breast cancer and other cancers in patients with Parkinson's disease. Int J Cancer 2012;131(8):1904-11.
  122. Birch-Johansen F, Jensen A, Olesen AB, et al. Does hormone replacement therapy and use of oral contraceptives increase the risk of non-melanoma skin cancer? Cancer Causes Control 2012;23(2):379-88.
  123. Nielsen K, Måsbäck A, Olsson H, et al. A prospective, population-based study of 40,000 women regarding host factors, UV exposure and sunbed use in relation to risk and anatomic site of cutaneous melanoma. Int J Cancer 2012;131(3):706-15.
  124. Wirdefeldt K, Weibull CE, Chen H, et al. Parkinson's Disease and Cancer: A Register-based Family Study. Am J Epidemiol. 2013 Oct 18.
  125. Li WQ, Qureshi AA, Ma J, et al. Personal History of Prostate Cancer and Increased Risk of Incident Melanoma in the United States. J Clin Oncol November 4, 2013 JCO.2013.51.1915.
  126. Kubo JT, Henderson MT, Desai M, et al. Alcohol consumption and risk of melanoma and non-melanoma skin cancer in the Women's Health Initiative. Cancer Causes Control. 2013 Oct 31.
  127. Wiren S, Haggstrom C, Ulmer H, et al. Pooled cohort study on height and risk of cancer and cancer death. Cancer Causes Control. 2013 Oct 31.
  128. Noel SE, Stoneham AC, Olsen CM, et al. Consumption of omega-3 fatty acids and the risk of skin cancers: a systematic review and meta-analysis. Int J Cancer. 2013 Nov 21. doi: 10.1002/ijc.28630.
  129. Li X, Wu XB, Chen Q. Statin use is not associated with reduced risk of skin cancer: a meta-analysis. Br J Cancer. 2014 Feb 4;110(3):802-7.
  130. Veierød MB, Couto E, Lund E, et al. Host characteristics, sun exposure, indoor tanning and risk of squamous cell carcinoma of the skin. Int J Cancer. 2013 Dec 6.
  131. Jung GW, Dover DC, Salopek TG. Risk of second primary malignancies following a diagnosis of cutaneous malignant melanoma or nonmelanoma skin cancer in Alberta, Canada from 1979 to 2009. Br J Dermatol. 2014 Jan;170(1):136-43.
  132. Fallah M, Pukkala E, Sundquist K, et al. Familial melanoma by histology and age: Joint data from five Nordic countries. Eur J Cancer. 2014 Apr;50(6):1176-83.
Updated: 22 April 2014